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Hemorragia digestiva baja (hdb)
Este documento trata sobre la hemorragia digestiva baja (HDB), definida como sangrado por debajo del ángulo de Treitz. Presenta estadísticas sobre su incidencia y causas más comunes como la diverticulosis y las angiodisplasias. Describe un caso clínico de HDB masiva y los exámenes endoscópicos y de imagen utilizados para diagnosticar la causa subyacente. Finalmente, resume las consideraciones generales y específicas para el tratamiento de la HDB.
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Hemorragia digestiva baja (hdb)
- 1. Encuentra las videosclasesen: http://www.youtube.com/channel/UCgZGxUTlxGuZV3MYDcLWEBg?feature=watch
- 2. HEMORRAGIA DIGESTIVA BAJA (HDB) HECTORPAUCAR SOTOMAYOR GASTROENTEROLOGIA FMH - UNSAAC
- 3. HEMORRAGIA DIGESTIVA BAJAHEMORRAGIADIGESTIVA BAJA HDBHDB SANGRADO POR DEBAJO DEL ANGULO DE TREITZ EPIDEMIOLOGIA: Incidencia: 20,5-27 x 100,000 Hab. Incrementa con la edad 10 - 24 % de todos los episodios de sangrado
- 4. CASO CLINICO Mujerde 76 años que acude por presentar deposiciones sanguinolentas abundantes (> 1 lt) hace 2 horas, sus familiares la encontraron desmayada y la trajeron inmediatamente al hospital No tiene antecedentes patologicos de importancia PA: 50/0 FC: 120 x min Palidez importante de piel y mucosas.
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- 7. HEMORRAGIA DIGESTIVA BAJA FORMASDE PRESENTACION CLINICAFORMAS DE PRESENTACION CLINICA HEMATOQUEZIA SIGNOS DE DESCOMPENSACION HEMODINAMICA
- 8. CAUSAS DE HDB Diverticulosis Angiodisplasia Hemorroides Fisuras anales Neoplasias Enfermedad intestinal inflamatoria Colitis Isquemica Colitis Infecciosa Colitis inducida por radiacion Diverticulo de Meckel Intusucepcion intestinal Fistula aortointestinal Ulceras rectales solitarias Ulceras cecales inducidas por AINEs
- 9. CAUSAS DE HDBEN EL PERU DIVERTICULOS DE COLON 50,4% FIEBRE TIFOIDEA 8,8% HEMORROIDES INTERNAS 5,9% ANGIODISPLASIA DEL COLON 3,7% CANCER DE COLON 2,9% OTROS 32,0% HNERM LIMA
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- 11. Afecta mas apoblacion geriatrica Complicacion (3%) de los pacientes que sufren diverticulosis Preponderante en colon sigmoides Hematoquezia masiva No hay dolor abdominal
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- 20. LOCALIZACION ANATOMICA DELA ANGIODISPLASIA COLONICA
- 21. ANGIODISPLASIA O ECTASIA VASCULAR Mayorfrecuencia en poblacion geriatrica Las lesiones suelen ser multiples y pequeñas (< 5 mm) y se ubican preferentemente en hemicolon derecho y ciego Se relacionan con enfermedad aortica (?)
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- 31. SANGRADO DIGESTIVO POR COLITISISQUEMICA
- 32. SANGRADO DIGESTIVO POR COLITISISQUEMICA
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- 36. SANGRADO DIGESTIVO POR ENFERMEDADINFLAMATORIA INTESTINAL
- 37. CAUSAS DIVERSAS DEHDB COLITIS INFECCIOSA HEMORROIDES INTERNAS
- 38. INVESTIGACION CLINICA REANIMACION HISTORIA CLINICA Y EXPLORACION FISICA ENDOSCOPIA ENDOSCOPIA DIGESTIVA ALTA COLONOSCOPIA GAMMAGRAFIA CON GR TC99 ANGIOGRAFIA MESENTERICA
- 39. HDB – TRATAMIENTO CONSIDERACIONESGENERALES: Las mismas que en HDA CONSIDERACIONES ESPECIFICAS: 60% dejan de sangrar en las 48 hs, 20% cesa la hemorragia pero se reanuda a las 48-72 hs, 20% continuan sangrando 1. Si continua sangrando y necesita mas de 2 unidades de sangre c/8 hs por 24 hs debe considerarse cirugia de emergencia con o sin diagnostico etiologico 2. Si vuelve a sangrar luego de 48-72 hs de haber cesado, compensar hemodinamicamente y luego pasar a cirugia. 3. Si ceso el sangrado, pero no tenemos diagnostico etiologico, re-evaluar con estudios diagnosticos adecuados o repetirlos.
- 40. TRATAMIENTO DE LAHDB REANIMACION MEDICACION ESPECIFICA ENDOSCOPIA TERAPEUTICA ANGIOGRAFIA TERAPEUTICA INTERVENCION QUIRURGICA
- 41. HEMORRAGIA DIGESTIVA BAJA Estimarvolumen de la perdida sanguinea Hb,Hto, Hem, Pruebas de coagulacion, GS y rH Via central, PVC, Sonda Foley (volumen urinario) PROCTOSIGMOIDOSCOPIA NEGATIVA TRATAMIENTO POSITIVA SNG – ENDOSCOPIA DIGESTIVA ALTA NEGATIVA CESO LA HEMORRAGIA DIGESTIVA CONTINUA LA HEMORRAGIA DIGESTIVA
- 42. HEMORRAGIA DIGESTIVA BAJA MASIVO COLONOSCOPIA RxDE COLON ARTERIOGRAFIA SCAN CON TC99 LENTO CESO LA HEMORRAGIA DIGESTIVA CONTINUA LA HEMORRAGIA DIGESTIVA POSITIVA NEGATIVA TRATAMIENTO ARTERIOGRAFIA POSITIVA NEGATIVA RE-EVALUACION TRATAMIENTO QUIRURGICO POSITIVO NEGATIVO TRATAMIENTO CIRUGIA COLONOSCOPIA INTRAOPERATO RIA
Notas del editor
- #18 Figure 7-20. Most bleeding from colorectal polyps and cancer is occult or mild and intermittent. Rarely polyps and cancer may cause significant lower gastrointestinal hemorrhage. Left-sided and rectal neoplasms are more likely to cause gross bleeding than right-sided lesions. Diagnosis is made by endoscopy or barium enema. Treatment for bleeding polyps or cancer is usually by colonoscopic removal or surgery. This figure depicts a pedunculated sigmoid polyp (A). A descending colon adenocarcinoma (B) and an annular rectal adenocarcinoma (C) are also shown. (A, Courtesy of J. Lappas, Indianapolis, IN)
- #19 Figure 7-20. Most bleeding from colorectal polyps and cancer is occult or mild and intermittent. Rarely polyps and cancer may cause significant lower gastrointestinal hemorrhage. Left-sided and rectal neoplasms are more likely to cause gross bleeding than right-sided lesions. Diagnosis is made by endoscopy or barium enema. Treatment for bleeding polyps or cancer is usually by colonoscopic removal or surgery. This figure depicts a pedunculated sigmoid polyp (A). A descending colon adenocarcinoma (B) and an annular rectal adenocarcinoma (C) are also shown. (A, Courtesy of J. Lappas, Indianapolis, IN)
- #21 Figure 7-14. Angiodysplasia are the most frequently encountered vascular abnormalities of the gastrointestinal tract and are a common etiology of lower gastrointestinal bleeding [14]. In patients with lower gastrointestinal bleeding, the prevalence of angiodysplasia ranges from 6% to 30%. Colonic angiodysplasia are more commonly found in the cecum and ascending colon. Pictured is the distribution of colonic angiodysplasia in one series of 59 patients. Multiple lesions are seen in 40% to 75% of patients. Bleeding is usually subacute and recurrent, but 15% of patients present with massive hemorrhage. In 90% of cases, bleeding stops spontaneously. With the advent of colonoscopy, angiodysplasia are often found in persons without evidence of bleeding. Of 964 asymptomatic patients undergoing colonoscopy for colorectal cancer screening, Foutch [19] found the prevalence of angiodysplasia to be 0.93%. (From Hochter et al. [20]; with permission.) References: [14]. Reinus JF, Brandt LJ, Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994 23 1-20 [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [20]. Hochter W, Weingart J, Kuhner W, et al. Angiodysplasia in the colon and rectum. Endoscopic morphology, localization, and frequency. Endoscopy 1985 17 182-185
- #23 Figure 7-15. Colonic angiodysplasia are thought to be acquired and associated with aging. Boley et al. [21] proposed that repeated intermittent low-grade obstruction of submucosal veins at the point where they crossed colonic muscle layers led to the development of angiodysplasia. A normal vein perforating the muscular layer is shown (A). The vein is partially obstructed because of muscular contraction or increased intraluminal pressure (B). Over a period of years, the submucosal vein becomes dilated and tortuous (C), the veins and venules draining into the submucosal vein become dilated (D), and the capillary ring becomes dilated, the precapillary sphincter becomes incompetent, and a small arteriovenous communication arises (E). Boley et al. [21] proposed that angiodysplasia were more prevalent in the right colon because of the increased diameter and wall tension. The factors responsible for the initiation of bleeding are unknown. (From Boley et al. [21]; with permission.) References: [21]. Boley SJ, Sammartano R, Adams A, On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology 1977 72 650-660
- #24 Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
- #25 Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
- #26 Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
- #27 Figure 7-16. Colonoscopy detects approximately 80% of colonic angiodysplasia. Lesions appear flat or slightly raised, red, and 2 to 10 mm in diameter. They may be round, stellate, or fernlike [19]. There may be a prominent feeding vessel or a pale mucosal halo (A-D). Many lesions may mimic angiodysplasia, including lesions of hereditary hemorrhagic telangiectasia, ischemia, radiation colitis, and suction artifacts. Lesions may be missed if the patient is anemic or volume depleted. The effect of narcotics on the endoscopic appearance of angiodysplasia is controversial. Narcotics may lead to vasoconstriction and decreased mucosal blood flow, thus obscuring angiodysplasia, whereas naloxone hydrochloride may act to reverse these vasoconstrictive effects [22]. References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818 [22]. Deal SE, Zfass AM, Duckworth PF, et al. Arteriovenous malformation (AVMs). Are they concealed by meperidine [Abstract]? Am J Gastroenterol 1991 86 1351-1351
- #28 Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
- #29 Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
- #30 Figure 7-17. The diagnostic yield of angiography for angiodysplasia is 17% to 20%. Classic findings include late draining veins (85% to 90%) representing obstructed submucosal veins (A), vascular tufts (70% to 75%) (B), early filling veins (60% to 80%) indicative of arteriovenous communication (C), and extravasation of contrast (6% to 20%) (not pictured) [19]. (Courtesey of N. Harris, Indianapolis, IN) References: [19]. Foutch PG, Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993 88 807-818
- #32 Figure 7-23. Most patients with ischemic colitis present with abdominal pain, however, 15% to 25% of patients may present with overt rectal bleeding. Complete absence of bleeding, including occult bleeding, is uncommon. Bleeding is occasionally massive. Endoscopy is the diagnostic procedure of choice. Endoscopically, rectal sparing is typical because of the middle rectal artery collateral circulation. Ischemic proctitis has primarily been reported in patients with extensive pelvic surgery and presumed disruption of rectal blood flow. A, The mucosa may be pale, edematous, and friable in early disease. B and C, The mucosa may also show a blue-black discoloration signifying mucosal necrosis and submucosal hemorrhage if the disease is extensive. The areas most commonly affected are the watershed areas of the splenic flexure and sigmoid colon, which are at the periphery of the inferior mesenteric artery circulation. Most patients with ischemic colitis have a self-limited course with spontaneous recovery. However, transmural necrosis and peritonitis may develop, and this possibility necessitates careful clinical observation. In some cases, healing may occur with subsequent stricture formation. (A, Courtesy of D. Johnson, Norfolk, VA) (B and C, Courtesy of R. Goulet, Indianapolis, IN)
- #33 Figure 7-23. Most patients with ischemic colitis present with abdominal pain, however, 15% to 25% of patients may present with overt rectal bleeding. Complete absence of bleeding, including occult bleeding, is uncommon. Bleeding is occasionally massive. Endoscopy is the diagnostic procedure of choice. Endoscopically, rectal sparing is typical because of the middle rectal artery collateral circulation. Ischemic proctitis has primarily been reported in patients with extensive pelvic surgery and presumed disruption of rectal blood flow. A, The mucosa may be pale, edematous, and friable in early disease. B and C, The mucosa may also show a blue-black discoloration signifying mucosal necrosis and submucosal hemorrhage if the disease is extensive. The areas most commonly affected are the watershed areas of the splenic flexure and sigmoid colon, which are at the periphery of the inferior mesenteric artery circulation. Most patients with ischemic colitis have a self-limited course with spontaneous recovery. However, transmural necrosis and peritonitis may develop, and this possibility necessitates careful clinical observation. In some cases, healing may occur with subsequent stricture formation. (A, Courtesy of D. Johnson, Norfolk, VA) (B and C, Courtesy of R. Goulet, Indianapolis, IN)
- #35 Figure 7-27. Approximately 2% to 5% of patients receiving radiation therapy for gynecologic, prostate, bladder, or rectal cancer will develop chronic radiation injury to the rectum and sigmoid colon. The extent and severity of the injury depends on the total dose of radiation and the volume of the bowel exposed. The pathogenesis of the injury is believed to involve radiation-induced vascular changes of the bowel wall with resultant tissue ischemia. Because of its fixed position in the pelvis, the rectum is damaged in 70% to 90% of all patients with intestinal radiation injuries. Patients usually present with intermittent rectal bleeding, tenesmus, and altered bowel habits. The bleeding may be slow, resulting in iron deficiency anemia, or occasionally, massive. A and B, Endoscopically there is mucosal erythema, edema, friability, and diffuse telangiectasias. An effective therapy for hemorrhage from radiation proctitis is endoscopic laser ablation or electrocautery of telangiectasias. Decreased transfusion requirements can be achieved using the Nd:YAG (neodymium:yttrium-aluminum-garnet) laser or argon laser. Medical therapy of radiation proctitis has met with limited success. Oral or rectal steroids and sulfasalazine, sucralfate enemas, intrarectal formalin, and hyperbaric oxygen have all been used, but no controlled trials of these modalities have been performed. Surgery is seldom used for radiation injury because of a substantial risk of complications.
- #37 Figure 7-28. Inflammatory bowel disease is a common cause of lower gastrointestinal bleeding in the younger patient. Rectal bleeding is a common manifestation of ulcerative colitis. Patients with Crohn's disease usually present with abdominal pain and diarrhea but may have bleeding. Bleeding in inflammatory bowel disease is usually recurrent and minor. Profuse bleeding develops in up to 6% of patients with ulcerative colitis or Crohn's disease. Robert et al. [41] evaluated 21 patients with Crohn's disease and severe gastrointestinal hemorrhage. They found that 66% of the patients had ileocolitis, 19% had entries alone, and 14% had colitis alone. The bleeding stopped spontaneously in 50% of the patients, but 33% had rebleeding. The authors advocated early surgical intervention in patients who have a high rebleeding rate. A, An endoscopic view of severe Crohn's colitis. B, Enteroclysis revealed terminal ileum involvement of Crohn's disease. C, A positive bleeding scan in a patient with Crohn's disease. D, Surgical resection specimen from a patient with Crohn's disease and severe bleeding. (B and C, Courtesy of J. Lappas, Indianapolis, IN) (D, Courtesy of R. Goulet, Indianapolis, IN) References: [41]. Robert JR, Sachar DB, Greenstein AJ, et al. Severe gastrointestinal hemorrhage in Crohn's disease. Ann Surg 1991 213 207-211